The LITFL Review 153

LITFL review

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

Welcome to the 153rd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerWhat do we do when our diagnostic capabilities outstrip our abilities to understand the disease and it’s necessary treatment? Rory Spiegel gives turns a critical eye onto the practice of cardiac catheterization for all cardiac diseases that aren’t STEMI. [AS]

The University of Maryland Emergency Medicine (UMEM) Department has been churning out high-yield pearls for years. Now, you can get the free UMEM app for free and bring those pearls directly to your handheld device. [AS]

The Best of #FOAMed Emergency Medicine

  • Looking for a way to reduce a mandibular dislocation without procedural sedation? Ryan Radecki reviews the syringe technique this week. [AS]
  •  More pearls from Amal Mattu’s EKG series. This week he covers the prolonged QT interval, the general causes and a great trick to narrow the differential without further testing. [AS]
  •  FOAMCast covers a rarely mentioned topic in FOAM; the spleen. Great pearls about asplenic patients, traumatic splenic injuries and more. [AS]
  • Although the recommendations seem to be rapidly changing, EM Basic gives a sensical, non-alarmist update on Ebola screening and treatment as of October 16th 2014. [AS]
  • emDocs.net offers a concise review of the literature surrounding outpatient treatment of low risk patients with pulmonary embolism. [AS]

The Best of #FOAMcc Critical Care

  • When should trauma patients get TXA? What is the ideal initial access in trauma patients? IO or CVL? FFP or PCC for coagulopathy of trauma and more questions via EM Lyceum. [AS]
  •  Trying to reduce advanced chest imaging in trauma? Check out a review from ALiEM on the NEXUS Chest rule. High sensitivity but low specificity. Many questions left unanswered but it’s a start. [AS]
  •  The Maryland CC Project features a great video cast reviewing Thromboelastometry (TEM) Guided Transfusion for Perioperative Coagulopathy with Klaus Gorlinger. [AS]
  •  The NICE guidelines for managing acute heart failure are out and it appears that no Emergency Physician is happy with its recommendations. St. Emlyn’s gives a nice critique of the key pieces. [AS]
  •  The VITdAL-ICU study looking at the effects of vitamin D supplementation in ICU was another fab study from ESICM in Barcelona. Oli Flower interviews the lead author here. [SO]
  •  THe Maryland CC Project (again!) has a wonderful lecture by Sanjay Desai on Ventilator Waveform analysis. [SO]
  •  Looking to make yourself more ECMO than EC-NO? The Alfred Hospital recently completed an ECMO course. Lots of handy tips were tweeted out, and have been wonderfully compiled by the INTENSIVE blog here. [SO]
  •  The Australia and New Zealand Intensive Care Society have a youtube page where lots of talks from their Annual Meetings have been recorded. Lots of wonderful #Foamcc to be imbibed- including a great talk by Chris Nickson on rapid response teams. [SO]
  •  More “great physiology in 1000 words” by Jon-Emile Kenny for Pulmccm: This time he tackles Stroke Volume Variation. [SO]
  •  CTA has replaced angiography as the standard diagnostic modality for a large number of indications but The Skeptics Guide to Emergency Medicine points out that CTA sensitivity for blunt cerebrovascular injury detection is suboptimal. A negative CTA for this indication should not end the diagnostic workup. [AS]

#FOAMTox Toxicology

#FOAMus Ultrasound

  • Handsonecho is an amazing FOAMus resource featuring links to courses and lots of video tips- including a large selection of tips on US from Daniel Lichtenstein himself! [SO]

#FOAMpeds Pediatrics

  • The PEMED podcast discusses a physically and mentally challenging clinical entity that is all too common – child abuse. Andy sits down with Marci Donaruma-Kowh to discuss cornerstone exam findings and red flags that will help you identify these patients and get them the protection and care they need. [AS]

News from the Fast Lane

Reference Sources and Reading List

The post The LITFL Review 153 appeared first on LITFL.

Emergenza Ebola: Cibinel all’Ansa “personale pronto soccorso formato per far fronte all’emergenza”

@SilviaAlparone

In una recente intervista con Ansa nazionale, il presidente Simeu, Gian Alfonso Cibinel, ha sottolineato che “i pronto soccorso italiani sono preparati a far fronte a un’eventuale emergenza per casi sospetti da virus Ebola e il protocollo di intervento predisposto dal ministero della Salute è arrivato a tutte le aziende sanitarie”. Nell’intervista, che è stata poi ripresa tra gli altri dai quotidiani La Repubblica e il Sole 24 ore, Cibinel ha precisato tuttavia la criticità di spazi dedicati per l’eventuale isolamento di casi sospetti, spazi che non sono disponibili in tutti i pronto soccorso.

Detto questo, medici e operatori dei pronto soccorso sono formati per far fronte a malattie infettive: “L’allerta è giusta – conclude Gian Alfonso Cibinel, ma non bisogna estremizzare e va sicuramente allentato il clima di paura che si sta diffondendo”.

Boring Questions: Do you even dip?

Urine is boring so we are doing a follow up post to Brent’s first ever post on BoringEM “Urinalysis Voodoo”. Less voodoo, more evidence.

The case:

Jane, a 23-year-old, sexually active female presents to the emergency department with a two day history of dysuria and urinary frequency. She has not experienced vomiting, fevers or changes in vaginal discharge. Her abdominal review of systems is negative. Her LMP was one week ago and she has had no new sexual partners in the past year. She has had one previous UTI two years ago. Her vital signs are normal and she has a temperature of 36.7. On abdominal exam she has mild suprapubic tenderness and no CVA percussion tenderness. Clinically, you suspect a urinary tract infection. Her urine dip is negative for nitrites, leukocytes and blood.The clinical question:

The clinical question:

Does a negative urine dip rule out a urinary tract infection in the presence of isolated lower urinary tract symptoms in an otherwise healthy, young female?

The Search Strategy: 

Search terms input to Pubmed and Google Scholar were:

  • “Test characteristics AND urine dip”
  • “sensitivity AND urinalysis”
  • “negative predictive value OR positive predictive value AND urinalysis”.

These terms were also searched with “systematic review” in Google scholar. The references of relevant papers were also reviewed. “Urinary tract infection” was searched in the The Cochrane Review Database but no relevant article on diagnosis was found.

The Evidence:

Pre-test probability: a JAMA systematic review [1] estimated that when a woman presents with one symptom of a UTI the baseline probability of infection is 50%. The review went on to outline the likelihood ratios (LR) associated with the presence and absence of symptoms associated with diagnosis.

  • Increase likelihood of UTI: dysuria (LR=1.5), frequency (LR=1.3), hematuria (LR=2.0) and back pain (LR=1.6).
  • Decrease likelihood of UTI: absence of dysuria (LR=0.5), absence of back pain (LR=0.8), history of vaginal discharge (LR=0.3), history of vaginal irritation (LR=0.2).
  • Non-contributory: Fever, abdominal pain, flank pain

*Jane’s pertinent positives and negatives, give her a pre-dipstick probability for UTI of 99% (50% x 1.5 x 1.3).

Test characteristics: A large systematic review [2] of 51 studies evaluated the combined test characteristics of leukocyte esterase/nitrites and two more recent studies [3,6] examined the test characteristics of each test independently.

 

Parameter
Sensitivity
Specificity
LR (+)
LR (-)
Leukocyte esterase and/OR Nitrite75%82%4.10.3
Leukocyte esterase44.2%85.2%2.90.53
Nitrite27.9%99.7%270.73

 Post-test probability

  • Because of the high pre-test probability even a negative dipstick does not rule out a urinary tract infection.

NB: Jane’s urine dip was negative giving her a post-test probability of 33% [99% x 0.3].

The Bottom Line: 

Urine dipstick analysis does not have a high enough negative LR to rule out urinary tract infection in those with a clinically high pre-test probability [6]. We will treat Jane’s symptoms with a short course of antibiotics and will not culture her urine [4, 5] something we would consider with any features suggesting a complicated infection, pyelonephritis or if she had recent antimicrobial treatment.

 

The not so boring question:

If the test is not going to change management then why do we continue to order it in this specific population?

 

Other FOAM on this topic

  • Best Bets “Accuracy of negative dipstick urinalysis in ruling out urinary tract infection in adults.”
  • Abbo et al. “Antimicrobial stewardship and urinary tract infections”
  • Brent Thoma’s first ever post on BoringEM “Urinalysis Voodoo

References

  1. Bent S, Nallamothu BK, Simel DL et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287(20):2701-2710. PMID: 12020306.
  2. Hurlbut T, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol.1991;96:582-588. PMID: 1951183.
  3. Schulz, T., Machado, M. J., Treitinger, A., Fiamoncini, A., & de Oliveira Niederauer, L. M. (2014). Risk associated with dipstick urinalysis for diagnosing urinary tract infection. pinnacle biochemistry research. Accessed at: http://www.researchgate.net/publication/260870381_Risk_associated_with_dipstick_urinalysis_for_diagnosing_urinary_tract_infection
  4. Takhar, S. S., & Moran, G. J. (2014). Diagnosis and Management of Urinary Tract Infection in the Emergency Department and Outpatient Settings. Infectious disease clinics of North America, 28(1), 33-48. PMID: 24484573
  5. Johnson, J. D., O’Mara, H. M., Durtschi, H. F., & Kopjar, B. (2011). Do urine cultures for urinary tract infections decrease follow-up visits?. The Journal of the American Board of Family Medicine, 24(6), 647-655.

Reviewing with the Staff (James Ahn)

Eve Purdy presents a compelling argument for discarding the urine dipstick when we have a high clinical pretest probability for a urinary tract infection (UTI). This is a viable strategy when approaching young and non-pregnant women who are otherwise healthy. If the sensitivity of a urine dipstick is not robust enough to dissuade treatment, then why waste the time and money?

UTIs are one of the most common infections seen in emergency department (ED). This is not an infrequent diagnosis; in the uncomplicated patient, UTIs should be rapid dispositions from the ED. A patient with a high pre-test clinical probability for UTI should be empirically treated with antibiotics. This strategy circumvents the need for urine from the emergency department, which at times can be harder to obtain than CSF! In the ED, the most precious resource is bed space, and any measure we can develop to increase turnover in a safe manner should be considered. Further, preforming a urine dip cost money to the patient and hospital, as well as provide a distraction to allied health professionals from other tasks.

In summary, the young, uncomplicated, and non-pregnant female who has high-risk factors for a UTI should be treated with antibiotics without the performance of a urine dip. The urine dipstick still holds a place in our diagnostic armamentarium for other patient populations and those who do not have such compelling historical risk factors.

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Boring Questions: Do you even dip? appeared first on BoringEM and was written by Eve Purdy.

Episode 23 Coming Soon

We realize there’s been a slight lag since the last episode. Rest assured we’re working on more great episodes and appreciate your patience. The show is a labor of love and some of that labor has had to go towards other areas recently. But there are some exciting changes coming to ToxTalk in the next few months and we think you’ll like them. So all we ask of you is to keep us in your subscription feed via iTunes or the mailing list or however you listen, and that way you’ll be there to see them. Those going through tox withdrawal can checkout our Twitter feed @ToxTalk which is still active or maybe checkout episodes you haven’t heard.

Thanks again!

The Trauma Pan-Scan Saves Lives

… and redeems them for valuable prizes.

Such is the message of this systematic review and meta-analysis, evaluating the published literature comparing “whole body CT”, arbitrary complete scanning, with “selective imaging”, scanning as indicated by physical examination.

Identifying seven studies, comprising 23,172 patients, these authors found a 20% reduction in mortality – 20.3% versus 16.9% – associated with the use of WBCT, despite a higher mean Injury Severity Score in the WBCT cohort.  The implication: choosing a selective scanning strategy was harmful, even in the face of a less-injured cohort.  Thus, the authors conclude the mortality advantage far exceeds any risks from radiation, and WBCT should be considered the standard method of evaluation.

Except, all but 2,610 of the patients in these pooled studies are from retrospective cohorts fraught with selection bias.  There are many reasons why trauma patients with lower ISS might yet have higher mortality, and otherwise aggressive diagnostic evaluation not indicated.  And, when those retrospective patients are tossed out, the comparison is a wash in the prospectively studied cohort.

If you’re a fan of selective imaging, this study probably changes little in your mind.  If you’re a fan of WBCT, it’s another citation to add to your quiver.  The authors of this study are hoping REACT-2 gives us the definitive answer – but with only 1,000 patients, I doubt that will be the case, either.

“Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: A systematic review and meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/25250591